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CDHO Advisory: Brain Tumours

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CDHO ADVISORY

SCOPE

RECOMMENDATIONS

BENEFITS/HARMS OF IMPLEMENTING THE RECOMMENDATIONS

CONTRAINDICATIONS

COLLEGE OF DENTAL HYGIENISTS OF ONTARIO ADVISORY

ADVISORY TITLE

Use of the dental hygiene interventions of scaling of teeth and root planing including curetting surrounding tissue, orthodontic and restorative practices, and other invasive interventions for persons1 with brain tumours.

ADVISORY STATUS

Cite as College of Dental Hygienists of Ontario, CDHO Advisory Brain Tumours, 2019-10-31

INTERVENTIONS AND PRACTICES CONSIDERED

Scaling of teeth and root planing including curetting surrounding tissue, orthodontic and restorative practices, and other invasive interventions (“the Procedures”).

SCOPE

DISEASE/CONDITION(S)/PROCEDURE(S)

Brain tumours

INTENDED USERS

Advanced practice nurses
Dental assistants
Dental hygienists
Dentists
Denturists
Dieticians
Health professional students
Nurses
Patients/clients
Pharmacists
Physicians
Public health departments
Regulatory bodies

ADVISORY OBJECTIVE(S)

To guide dental hygienists at the point of care relative to the use of the Procedures for persons who have brain tumours, chiefly as follows.

  1. Understanding the medical condition.
  2. Sourcing medications information.
  3. Taking the medical and medications history.
  4. Identifying and contacting the most appropriate healthcare provider(s) for medical advice.
  5. Understanding and taking appropriate precautions prior to and during the Procedures proposed.
  6. Deciding when and when not to proceed with the Procedures proposed.
  7. Dealing with adverse events arising during the Procedures.
  8. Keeping records.
  9. Advising the patient/client.

TARGET POPULATION

Child (2 to 12 years)
Adolescent (13 to 18 years)
Adult (19 to 44 years)
Middle Age (45 to 64 years)
Aged (65 to 79 years)
Aged 80 and over
Male
Female
Parents, guardians, and family caregivers of children, young persons and adults with brain tumours.

MAJOR OUTCOMES CONSIDERED

For persons who have brain tumours: to maximize health benefits and minimize adverse effects by promoting the performance of the Procedures at the right time with the appropriate precautions, and by discouraging the performance of the Procedures at the wrong time or in the absence of appropriate precautions.

RECOMMENDATIONS

UNDERSTANDING THE MEDICAL CONDITION

Terminology used in this Advisory

Resources consulted

Brain tumours, cerebral tumours, are tumours that 

  1. are classified as 
    1. primary tumours, which are of two types
      1. benign tumours, which 
        1. develop within the brain and do not spread to or from the brain
        2. do not comprise malignant cells
        3. are not harmless because they cause harm by compressing
          1. surrounding tissues 
          2. structures within the skull
      2. malignant tumours
    2. secondary tumours, which 
      1. spread to the brain from tumours elsewhere in the body
      2. are malignant
  2. mostly are of unknown cause
  3. may occur at any age 
  4. create symptoms and signs that depend on the tumour’s size and location in the brain. 

Other terminology used in this Advisory is as follows.

  1. Benign tumours of the brain, which create signs and symptoms no one of which is unique to brain tumours, including
    1. balance problems
    2. change in sense of smell
    3. changes in mental ability, such as
      1. concentration
      2. memory
      3. speech
    4. facial paralysis
    5. headaches
    6. hearing problems
    7. nausea and vomiting
    8. seizures
    9. vision problems.
  2. Germ cells, primitive cells that 
    1. develop in the embryo
    2. normally create the reproductive system. 
  3. Glial cell, a supportive cell of the central nervous system which differs from a neuron. 
  4. Malignant tumours of the brain are 
    1. generally serious
    2. often life threatening 
    3. likely to grow rapidly and cause damage by
      1. exerting pressure on surrounding healthy brain tissue
      2. invading surrounding healthy brain tissue.
  5. Neurons are
    1. cells of the nervous system that are specialized to carry electrochemical messages
    2. classified by the direction in which they send the messages
      1. sensory neurons, also called afferent neurons, which send messages from sensory receptors to the central nervous system
      2. motor neurons, also called efferent neurons, which
        1. send messages from the central nervous system to muscles or glands
        2. comprise
          1. upper motor neurons, which reside in the part of the brain’s cortex that governs movement
          2. lower motor neurons, which reside in the spinal cord
    3. include interneurons, which transmit messages between sensory neurons and motor neurons.
  6. Primary tumours of the brain are named according  to either the 
    1. part of the brain or nerves close to the brain in which they arise 
    2. type of cells they comprise
    3. include
      1. vestibular schwannoma (formerly known as acoustic neuroma), a benign tumour which arises 
        1. in the vestibular nerve, which controls balance
        2. in the cochlear nerve, which serves hearing
        3. most often in adults 
      2. astrocytoma, a malignant tumour which arises 
        1. from astrocytes, star-shaped glial cells
        2. in adults, most often in the cerebrum
        3. in children, most often in the 
          1. brain stem
          2. cerebellum 
          3. cerebrum
      3. brain stem glioma, a malignant tumour which arises 
        1. in the lowest part of the brain
        2. most often in 
          1. young children
          2. middle-aged adults 
      4. craniopharyngioma, a benign tumour which arises
        1. at the base of the brain, near the pituitary gland
        2. most often in children 
      5. ependymoma, a malignant tumour which arises
        1. from cells that line the
          1. ventricles of the brain
          2. central canal of the spinal cord
        2. most commonly in 
          1. children
          2. young adults 
      6. germ cell tumour of the brain, which may be a benign tumour or a malignant tumour, arises
        1. from a germ cell
        2. mostly before the age of 30 years
      7. medulloblastoma, a malignant tumour which  
        1. arises in the cerebellum
        2. is the most common brain tumour in children 
      8. meningioma, a benign tumour which 
        1. arises in the meninges
        2. usually grows slowly 
      9. oligodendroglioma, a malignant tumour which  
        1. arises in the cerebral hemispheres, usually in the cerebrum
        2. grows slowly and usually does not spread into surrounding brain tissue
        3. is most common in middle-aged adults.
  7. Primary cancer, as distinct from primary brain cancer, refers to the site in the body where the cancerous cells originate before spreading to the brain, where they develop into secondary tumours.
  8. Radiation necrosis, death of healthy brain tissue caused by radiation therapy, which may result in 
    1. death
    2. headaches
    3. seizures.
  9. Secondary tumours in the brain
    1. are also known as metastatic tumours
    2. result from cancer cells spreading from primary cancers in any part of the body, such as
      1. lung
      2. breast
      3. colon
      4. kidney
      5. skin (melanoma)
    3. occur more commonly than primary tumours of the brain
    4. generally have the same type of abnormal cells as the primary cancer
    5. mostly occur in the cerebrum, but may also occur in the cerebellum or brain stem 
    6. occur in the brain as multiple tumours 
    7. are common among men and women who are middle-aged or elderly
  10. Seizure
    1. is manifested as some combination of
      1. sudden alteration of behaviour
      2. minor physical signs
      3. thought disturbances 
    2. results from a temporary change in the electrical functioning of the brain,  particularly in the cortex
    3. occurs with various conditions, and not only brain tumours
    4. has oral risks including
      1. chipping of teeth
      2. biting of the tongue or cheeks.
  11. Shunt, surgical treatment 
    1. to drain excess fluid from the brain
    2. that involves a slender tube 
      1. placed in a ventricle of the brain
      2. threaded under the skin to the abdomen or other part of the body. 
  12. Tumour grade, which is based on microscopy of the tumour tissue, is used to denote malignancy; the higher the grade the more abnormal are the cells and the faster they are likely to spread.

Overview of brain tumours

Resources consulted

Brain tumours

  1. primary tumours
    1. types include
      1. gliomas, which originate in glial cells, and which are the most common of the primary brain tumours, such as
        1. astrocytoma 
        2. brain stem glioma 
        3. ependymoma 
        4. oligodendroglioma  
      2. non-glioma tumours which do not begin in glial cells, such as 
        1. craniopharyngioma 
        2. germ cell tumour of the brain
        3. medulloblastoma 
        4. meningioma
        5. vestibular schwannoma
      3. tumours of the pituitary gland (CDHO Advisory)
    2. causes 
      1. are unknown
      2. may include genetic factors
    3. risk factors, which increase the chances of development of a primary brain tumour, include 
      1. age
        1. most brain tumours are detected in people who are 70 years old or older 
        2. brain tumours are the second most common cancer in children 
      2. exposure to workplace radiation and certain workplace chemicals 
      3. family history of glioma may be associated with increased risk of this tumour 
      4. gender
        1. meningiomas are more common in females
        2. brain tumours generally are more common in males
      5. race: brain tumours occur more often among white people than among people of other races
  2. secondary tumours
    1. are increasing in frequency of occurrence because survival from primary cancers is improving
    2. are more common than primary brain tumours
    3. result from spread from tumours in other parts of the body, such as
      1. bladder cancer
      2. breast cancer
      3. kidney cancer
      4. lung cancer
      5. melanoma
      6. sarcomas
      7. testicular and germ cell tumour
    4. press on and invade adjacent parts of the brain
    5. cause swelling of the brain, which increases the intracranial pressure
    6. are associated with symptoms such as
      1. behavioural and cognitive changes 
      2. coordination problems 
      3. headaches 
      4. seizures 
    7. are treated variously with
      1. surgery and radiosurgery
      2. whole brain radiation therapy (CDHO Advisory)
      3. chemotherapy (CDHO Advisory)
    8. are associated with a prognosis that is poor because
      1. of the absence of a cure for secondary brain tumours
      2. the tumours spread within and beyond the brain to other parts of the body
      3. death frequently occurs within two years of diagnosis
  3. signs and symptoms of brain tumours generally
    1. vary according to the tumour type, size and location
    2. may be associated with pressure by
      1. the tumour on adjacent brain tissues or nerves
      2. swelling of the brain
      3. fluid build-up in the brain 
    3. occur with conditions other than brain tumours and are therefore not certain diagnostic indicators; variously include
      1. balancing or walking problems 
      2. changes in mood, personality, concentration or behaviour
      3. changes in 
        1. speech
        2. vision, loss or double vision
        3. hearing 
      4. coordination problems, clumsiness and falling
      5. fever
      6. headaches, of recent onset or unusual type
      7. lethargy and fatigue
      8. memory challenges, poor judgment, difficulty solving problems
      9. nausea or vomiting 
      10. numbness or tingling in the arms or legs 
      11. pain and other changes in sensation
      12. personality changes
      13. seizures
      14. speech problems
      15. weakness of a body area
    4. in children below the age 7, who appear to be especially at risk of cognitive problems which creates difficulties with
      1. attention and concentration
      2. memory
      3. mental processing of information
      4. planning, insight, initiative, and organizational competencies 
      5. visual perception skills
  4. medical investigation and diagnosis rests on
    1. the medical history and physical examination
    2. tests such as
      1. CT scan 
      2. MRI
      3. angiogram 
      4. skull x-ray 
      5. spinal tap 
      6. myelogram 
      7. biopsy, including
        1. needle biopsy 
        2. stereotactic biopsy
        3. biopsy at the same time as treatment 
  5. treatment, which  
    1. offers no cure for secondary brain tumours
    2. varies
      1. according to the tumour type, size and location
      2. with the age and state of health of the person
    3. includes some combination of 
      1. surgery
      2. radiation therapy (CDHO Advisory)
      3. chemotherapy (CDHO Advisory)
    4. supportive or palliative care, including
      1. medication  
        1. steroids, commonly used to help relieve brain swelling 
        2. anticonvulsants, to prevent or control seizures caused by brain tumours 
      2. shunt
  6. prognosis for brain tumours in general
    1. as expressed by survival rate varies widely, and which
      1. depends on the
        1. tumour 
          1. type 
          2. location and size, which determines whether the tumour can be removed surgically or not
          3. grade
          4. how soon it was detected
        2. person’s 
          1. age 
          2. ability to function
          3. response to treatment
        3. presence of comorbidities, complications and associated conditions 
      2. has improved with recent advances in surgical and radiation treatments
    2. in children 
      1. is more encouraging because survival rates 
        1. have dramatically increased following advances in treatment 
        2. are 5 years or better for 75 percent of children diagnosed with a brain tumour
      2. is less encouraging because of neurological complications associated with the 
        1. tumour
        2. treatment, such as 
          1. cranial radiation therapy (CDHO Advisory)
          2. chemotherapy (CDHO Advisory)
    3. as expressed as 
      1. life expectancy 
        1. secondary brain tumours (until the late 2000s was measured in months, as stated below, but since then aggressive treatment has resulted in somewhat longer survival rates; this has meant that neurosurgery is increasingly being used to treat brain metastases)
          1. without radiation therapy, 1-month mean life expectancy
          2. with radiation therapy, 4 to 6-month mean life expectancy  
        2. tumours that result in seizures, 6-month mean life expectancy 
      2. five-year survival rate for all persons with cancerous brain tumours are variously estimated to be
        1. aged 0 to 19 years, 66 percent
        2. aged 15 to 44 years, 55 percent 
        3. aged 45 to 64 years, 16 percent
        4. aged 65 years and over, 5 percent
    4. is improved only to a modest degree by 
      1. radiation therapy because the dosage of radiation needed to kill cancer cells in the brain also damages sensitive brain tissues, though techniques are improving
      2. chemotherapy because cancer cells in the brain may become resistant to chemotherapy medications, though the effectiveness of medications is improving
    5. is worsened because malignant brain tumours often recur 6 to 12 months after the initial diagnosis
  7. social considerations arising from the particular effects of brain tumours, which
    1. are devastating to the person and caregivers
    2. can to some extent be alleviated by appropriate support services 
    3. call for appropriate educational accommodation for children
    4. are supported by resources such as the following in 
      1. Canada
        1. Childhood Cancer Canada
        2. Brain Tumour Foundation of Canada
        3. Canadian Cancer Society
      2. the US
        1. American Cancer Society
        2. American Brain Tumor Association

Multimedia and images

Brain

Comorbidity, complications and associated conditions

Comorbid conditions are those which co-exist with brain tumours but which are not believed to be caused by it. Complications and associated conditions are those that may have some link with it. Distinguishing among comorbid conditions, complications and associated conditions may be difficult in clinical practice. 

Comorbid conditions, complications and associated conditions of brain tumours include the following.

  1. Impairment of mental and neurological function, including 
    1. loss of 
      1. ability to function
      2. ability for self-care 
      3. ability to interact with others
    2. permanent, progressive, and profound effects on neurological function 
    3. dementia (CDHO Advisory).
  2. Side effects of treatment for brain tumours 
    1. generally, which 
      1. arise because treatment may damage healthy cells and tissues, leading to temporary or permanent
        1. personality changes
        2. cognitive changes
        3. seizures
      2. may vary 
        1. among persons
        2. in the same person from time to time
    2. chemotherapy (CDHO Advisory) and radiation therapy (CDHO Advisory) which slow or stop the growth of rapidly dividing cells but which also affect normal as well as cancer cells, and may thus cause harm to the normal cells of the
      1. oral mucosa, leading to mouth ulcers
      2. intestines, leading to intestinal disorders
      3. other tissues
    3. surgery, which includes post-operative
      1. headache for the first few days 
      2. fatigue and weakness, which may persist 
      3. edema, which is treated with
        1. steroids
        2. shunt
    4. post-operative infection, treated with antibiotics. 
  3. Side effects of radiation therapy (CDHO Advisory), which 
    1. may be exacerbated when combined with chemotherapy (CDHO Advisory), include post-treatment
      1. nausea
      2. fatigue
      3. hair loss
      4. skin redness and other changes
      5. edema of brain tissues, causing headaches
      6. radiation necrosis
      7. damage to the pituitary gland and other areas of children’s brains.
  4. Side effects of chemotherapy (CDHO Advisory)
    1. depend on the medications employed
    2. commonly include
      1. fever and chills
      2. nausea and vomiting
      3. loss of appetite
      4. weakness.
  5. Side effects of medications arising from
    1. medication interactions
    2. duplicate prescriptions
  6. Mental-health considerations for survivors of malignant brain tumours who are able to return to work and who report 
    1. various limitations that affect their work
    2. need for additional time off.

Oral health considerations

Dental hygienists have a key role in relation to the treatment of brain tumours, as follows.

  1. Oral health should be optimized before, during, and after cancer treatment because many of the oral effects of treatment can be minimized by continuing attention to oral hygiene.
  2. The continuing attention to oral health
    1. requires
      1. communication and collaboration with
        1. family physicians 
        2. specialist services, including
          1. chemotherapy
          2. radiation therapy
          3. dental services specialized for survivors with major dental developmental disorders
          4. therapeutic services, such as
            1. dietary and nutritional therapy
            2. occupational therapy
            3. physical therapy
            4. speech and language therapy
          5. social services for patients/clients with evidence of 
            1. social-stress-related needs
            2. educational needs
          6. family caregivers and support groups
      2. accurate medical histories, especially relating to treatment, including
        1. age at which treatment started
        2. types of treatments received
        3. overview of current regimens for
          1. chemotherapy
          2. radiation therapy
        4. pain medications, specifically in relation to acetaminophen, because
          1. early in 2011, the US FDA reminded healthcare professionals to advise patients 
            1. not to exceed the acetaminophen maximum total daily dose of 4 grams/day
            2. not to consume alcohol while taking acetaminophen-containing medications
          2. a number of the medications used to treat pain from brain tumours may contain acetaminophen
          3. many over-the-counter, non-prescription medications contain acetaminophen
      3. appropriate liaison with services provided to 
        1. survivors of childhood brain tumours, especially those treated from an early age
        2. survivors and persons under treatment for lingering problems
      4. support for self-care and family caregiving, as appropriate
      5. continuing dental hygiene care scheduled according to needs.
  3. Oral side effects of brain cancer treatment 
    1. of children who 
      1. are under the age of 6 years and who are treated with chemotherapy and or radiation therapy and, as a result, who are at high risk for dental problems, such as
        1. missing adult teeth
        2. weakening of the enamel
        3. short roots
      2. prior to the brain cancer treatment had pre-existing oral health conditions, such as gum disease, require continuing dental hygiene and other oral healthcare
      3. are survivors of childhood brain tumours and who 
        1. may experience numerous dental problems requiring extensive dental treatment
        2. comprise a population of oral health patients/clients who should be followed carefully for the rest of their lives
      4. are unable for any reason to adequately undertake oral self-care should be assisted by parents who
        1. brush their children’s teeth 
        2. encourage their children’s avoidance of a sugar-rich diet
    2. of persons with poor mouth care and poor dental health at the time of cancer treatment who, as a result, may subsequently experience increased frequency and severity of oral side effects should be 
      1. assisted with oral self-care instruction
      2. encouraged to continue and maintain good oral hygiene 
    3. of survivors with major dental developmental disorders which required specialized dental care
    4. relate to
      1. chemotherapy which, because of distribution in the blood stream, has the potential to affect any cell in the body, and may
        1. reduce circulating white cells 
        2. weaken the immune system
      2. radiation therapy, which generally affects only cells in the path of the radiation, causes
        1. changes in the salivary glands, resulting in dry mouth
        2. scarring of oral tissue
    5. generally may 
      1. retard healing 
      2. cause dry mouth, which facilitates tooth decay and infection
      3. alter taste sensation.

MEDICATIONS SUMMARY

Sourcing medications information

  1. Adverse effect database
  2. Specialized organizations
  3. Medications considerations
    All medications have potential side effects whether taken alone or in combination with other prescription medications, or as over-the-counter (OTC) or herbal medications.
  4. Information on herbals and supplements 
  5. Complementary and alternative medicine

Types of medications

  1. Steroids for treatment of brain edema, which  
    1. reduce edema in the brain
    2. help relieve pre-surgery symptoms
    3. may be prescribed at diagnosis, or before or after surgery
    4. do not kill tumour cells
    5. may be taken alone or combined with other forms of treatment
    6. are gradually tapered off when the swelling is under control
    7. include
  2. Osmotic diuretics to reduce brain edema, including
    1. urea
    2. mannitol 
  3. Anti-epileptic drugs, also called anticonvulsants, for treatment of seizures, including
  4. Chemotherapy drugs prescribed for brain tumour patients, including
  5. Medications to reduce pain and emotional problems 
    1. The WHO Pain Ladder, which was reviewed in 2010, aims to achieve freedom from cancer pain 
      1. as a three-step process in the following order
        1. non-opioids, such as
        2. weak opioids, such as 
        3. strong opioids, such as  
      2. with help from adjuvants, which
        1. may be given at any stage to calm fears and anxiety, and/or relieve depression
        2. include
  6. Antacids or antihistamines, or proton pump inhibitors to treat excess stomach acid secretion.

Side effects of medications

See the links above to the specific medications. 

THE MEDICAL AND MEDICATIONS HISTORY

The dental hygienist in taking the medical  and medications history-taking should 

  1. focus on screening the patient/client prior to treatment decision relative to
    1. key symptoms
    2. medications considerations
    3. contraindications
    4. complications
    5. comorbidities
    6. associated conditions
    7. new conditions
  2. explore the need for advice from the primary or specialized care provider(s)
  3. inquire about
    1. pointers in the history of significance to brain tumours, such as 
      1. the types of treatments received 
      2. pain medications taken, prescribed or over-the-counter
    2. indications of difficulties with oral self-care
    3. the patient/client’s understanding and acceptance of the need for oral healthcare
    4. problems with previous dental/dental hygiene care
    5. problems with infections generally and specifically associated with dental/dental hygiene care
    6. the patient/client’s current state of health
    7. how the patient/client’s current symptoms relate to
      1. oral health
      2. health generally
      3. recent changes in the patient/client’s condition.

IDENTIFYING AND CONTACTING THE MOST APPROPRIATE HEALTHCARE PROVIDER(S) FOR ADVICE

Identifying and contacting the most appropriate healthcare provider(s) from whom to obtain medical or other advice pertinent to a particular patient/client

The dental hygienist should

  1. record the name of the physician/primary care provider most closely associated with the patient/client’s healthcare, and the telephone number
  2. obtain from the patient/client or parent/guardian written, informed consent to contact the identified physician/primary healthcare provider
  3. use a consent/medical consultation form, and be prepared to securely send the form to the provider
  4. include on the form a standardized statement of the Procedures proposed, with a request for advice on proceeding or not at the particular time, and any precautions to be observed.

UNDERSTANDING AND TAKING APPROPRIATE PRECAUTIONS

Infection Control

Dental hygienists are required to keep their practices current with infection control policies and procedures, especially in relation to

  1. the CDHO’s Infection Prevention and Control Guidelines (2022)
  2. relevant occupational health and safety legislative requirements
  3. relevant public health legislative requirements
  4. best practices or other protocols specific to the medical condition of the patient/client.

DECIDING WHEN AND WHEN NOT TO INITIATE THE PROCEDURES PROPOSED

The dental hygienist 

  1. should not implement the Procedures without prior consultation with the appropriate primary or specialist care provider(s)
    1. if the patient/client’s treatment includes chemotherapy or radiation therapy
    2. if the patient/client has undergone or is about to undergo surgery in connection with a brain tumour
    3. if the patient/client is receiving corticosteroid therapy (e.g., for management of cerebral edema or to minimize risk of side-effects and encephalopathy from radiotherapy), which may be associated with immunosuppression +/- increased risk of infection
  2. may postpone the Procedures pending medical advice if the patient/client 
    1. appears debilitated
    2. is experiencing symptoms suggestive of complications of brain tumours or its treatment 
    3. has not complied with pre-medication as directed by the prescribing physician 
    4. has recently changed significant medications, under medical advice or otherwise
    5. recently experienced changes in his/her medical condition such as medication or other side effects of treatment
    6. is unable to provide the dental hygienist with sufficient information about
      1. medications
      2. current or prior treatment
    7. has symptoms or signs of 
      1. side effects of treatment or medications
      2. comorbidity, complication or an associated condition of brain tumours
    8. not recently or ever sought and received medical advice relative to oral healthcare procedures
    9. is deeply concerned about any aspect of his or her medical condition.

DEALING WITH ANY ADVERSE EVENTS ARISING DURING THE PROCEDURES

Dental hygienists are required to initiate emergency protocols as required by the College of Dental Hygienists of Ontario’s Standards of Practice, and as appropriate for the condition of the patient/client.

First-aid provisions and responses as required for current certification in first aid.

RECORD KEEPING

Subject to Ontario Regulation 9/08 Part III.1, Records, in particular S 12.1 (1) and (2) for a patient/client with a history of brain tumours, the dental hygienist should specifically record

  1. a summary of the medical and medications history
  2. any advice received from the physician/primary care provider relative to the patient/client’s condition
  3. the decision made by the dental hygienist, with reasons
  4. compliance with the precautions required
  5. all Procedure(s) used
  6. any advice given to the patient/client.

ADVISING THE PATIENT/CLIENT

The dental hygienists should 

  1. urge the patient/client to alert any healthcare professional who proposes any intervention or test to 
    1. the history of treatment for brain tumour
    2. the pain-relieving medications used
  2. should discuss, as appropriate 
    1. the importance of
      1. checking the mouth regularly for new signs or symptoms
      2. reporting any changes in the mouth
    2. the need for regular oral health examinations and preventive oral healthcare 
    3. oral self-care including information about 
      1. choice of toothpaste
      2. tooth-brushing techniques and related devices
      3. dental flossing
      4. mouth rinses
      5. management of a dry mouth 
    4. the importance of an appropriate diet in the maintenance of oral health
    5. for persons at an advanced stage of a disease or debilitation
      1. regimens for oral hygiene as a component of supportive care and palliative care
      2. the role of the family caregiver, with emphasis on maintaining an infection-free environment through hand-washing and, if appropriate, wearing gloves
      3. scheduling and duration of appointments to minimize stress and fatigue 
    6. comfort level while reclining, and stress and anxiety related to the Procedures
    7. medication side effects such as dry mouth, and recommend treatment
    8. mouth ulcers and other conditions of the mouth relating to brain tumours, comorbidities, complications or associated conditions, medications or diet
    9. pain management.

BENEFITS/HARMS OF IMPLEMENTING THE RECOMMENDATIONS

POTENTIAL BENEFITS

  1. Promoting health through oral hygiene for persons who have or who have received, are receiving or are likely to receive treatment for brain tumours.
  2. Reducing the adverse effects, such as oral side effects of brain tumour treatments, by
    1. optimizing oral hygiene before, during and after brain-cancer treatment
    2. communicating and collaborating with healthcare providers
    3. aligning dental hygiene with other therapy services
    4. taking accurate medical and medications histories.
  3. Reducing the risk that oral health needs are unmet.

POTENTIAL HARMS

  1. Causing physical harm through failure to be prepared for the possibility of seizure.
  2. Performing the Procedures at an inappropriate time, such as 
    1. in the absence of adequate preparations for the possibility of seizure
    2. in the absence of prior, necessary medical advice 
    3. in the absence of sufficient attention to the
      1. effects of loss of
        1. mental and neurological function
        2. movement and coordination limitations
      2. oral side effects of treatments
    4. in the presence of complications for which prior medical advice is required.
  3. Disturbing the normal dietary and medications routine of a person with brain tumours.
  4. Inappropriate management of pain or medication.

CONTRAINDICATIONS

CONTRAINDICATIONS IN REGULATIONS

Identified in the Dental Hygiene Act, 1991 – O. Reg. 218/94 Part III

ORIGINALLY DEVELOPED

2011-07-01

DATE OF LAST REVIEW

2019-10-31

ADVISORY DEVELOPER(S)

College of Dental Hygienists of Ontario, regulatory body
Greyhead Associates, medical information service specialists

SOURCE(S) OF FUNDING

College of Dental Hygienists of Ontario

ADVISORY COMITTEE

College of Dental Hygienists of Ontario, Practice Advisors

COMPOSITION OF GROUP THAT AUTHORED THE ADVISORY

Dr Gordon Atherley
O StJ , MB ChB, DIH, MD, MFCM (Royal College of Physicians, UK), FFOM (Royal College of Physicians, UK), FACOM (American College of Occupational Medicine), LLD (hc), FRSA

Dr Kevin Glasgow
MD, MHSc, MBA, DTM&H, CHE, CCFP, DABPM, LFACHE, FCFP, FACPM, FRCPC

Lisa Taylor
RDH, BA, MEd

Kyle Fraser
RDH, BComm, BEd, MEd

ACKNOWLEDGEMENTS

The College of Dental Hygienists of Ontario gratefully acknowledges the Template of Guideline Attributes, on which this advisory is modelled, of The National Guideline Clearinghouse™ (NGC), sponsored by the Agency for Healthcare Research and Quality (AHRQ), U.S. Department of Health and Human Services.

Denise Lalande
Final layout and proofreading

© 2011, 2019 College of Dental Hygienists of Ontario

FOOTNOTES

1 Persons includes young persons and children.